Several years ago, Mickey Trockel, MD, PhD, had his mom visiting California from Washington. She developed severe right upper quadrant abdominal pain and went to the emergency department. Because of the surgeon’s dedication to detail, Dr. Trockel saw the capacity physicians have to accomplish amazing things.
Dr. Trockel’s mother was diagnosed with cholecystitis. The surgeon felt her level of pain exceeded what he observed in other patients with cholecystitis. Based on that judgement, the surgeon performed an exploratory laparoscopy and found a constriction in her bowel. The surgeon cut the restriction, which helped alleviate her pain.
“The outcome was amazing and the difference that he made was phenomenal. It was this very astute, present physician who was able to save her. That’s what physicians do when they’re at their best, if he had been burned out and less attentive I suspect her outcome would have been very different,” Dr. Trockel, who directs scholarship and health promotion at the Stanford University School of Medicine WellMD Center.
Dr. Trockel spoke at the 2019 American Conference on Physician Health, co-sponsored by the AMA, Mayo Clinic and Stanford Medicine.
Committed to making physician burnout a thing of the past, the AMA has studied, and is currently addressing issues causing and fueling physician burnout—including time constraints, technology and regulations—to better understand and reduce the challenges physicians face. By focusing on factors causing burnout at the system-level, the AMA assesses an organization’s well-being and offers guidance and targeted solutions to support physician well-being and satisfaction.
To improve the culture in medical practices and organizations, Dr. Trockel offered three steps to enhance physician well-being and reduce burnout.
Low self-valuation, or self-compassion, is a strong determinant of physician burnout. Physicians later in life often do better than young doctors in this area, as they learn with decades of experience to face errors with more intent to learn and less self-condemnation.
To emphasize this, Dr. Trockel shared a poem published in JAMA by Michelle Kittleson, MD, PhD, a cardiologist in Beverly Hills. In the poem, called “Mistakes,” the persona keeps kind notes from patients in a desk drawer, but mistakes get replayed in the doctor’s mind on sleepless nights.
Dr. Kittleson’s poem ends: “The stash of kind notes / Never sees the light, but the / Mental file stays fresh. / Happy endings, all / Alike. But every mistake / Cuts in its own way.”
This resonates with a lot of physicians, said Dr. Trockel, adding that “it cuts at the core of what I think is part of our self-valuation.”
While self-compassion is often a hard sell, it is important for improving physician well-being. In a recent study based on data from nearly 4,000 physicians published by Dr. Trockel, every one-point increase in a physician’s self-valuation was associated with a significant drop in level of burnout.
Together, physicians shape the medical environment they practice in, which in return shapes them. For example, constant negative feedback leads to burnout, which lowers performance and can lead to lawsuits and other negative outcomes. However, positive feedback and impact leads to professional fulfillment, which can improve performance and positive outcomes.
Research at Stanford, funded by the Physicians Foundation, is testing one way to encourage positive feedback, through a program called Influencing and Modeling Physician Action for Culture Transformation. This approach is based on the hypothesis that physicians may be more likely than others to influence doctors.
Physicians were asked to name three people they work with whom they respect the most—personally and professionally. These popular opinion leaders were subsequently recruited to help promote wellness skills—starting with work-specific gratitude practices and subsequently additional skills including cognitive reframing and mindfulness.
In as-yet-unpublished survey study, Dr. Trockel and his colleagues observed that, compared with their colleagues with the lowest quartile, physicians with the highest quartile of “negative impact of work on personal relationships” have 31 times the odds of burnout.
While listening to an ACPH session led by Cormac O’Donovan, MD, Dr. Trockel thought more about personal relationships. Dr. O’Donovan had asked, “Who are you to the ones you love?”
After Dr. Trockel called his wife and asked her if he had been demonstrating how important she and the family are to him, she struggled with her answer. Similar to Dr. Trockel’s work with physician well-being at Stanford, his wife said she saw “maybe a little bit of improvement” and that “we’ve got a lot of work to do still.”
However, she did say she was pleased that Dr. Trockel was able to drive their daughter to the train every morning—an act that added to Dr. Trockel’s well-being.
“I was grateful that I spent these mornings with my child. It really matters and it affects our well-being at work,” said Dr. Trockel. “Valuing ourselves, valuing our colleagues and valuing our personal relationships are the heart of a culture of wellness in medicine.”